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INTERVIEW: Improve Patient Care and Avoid EHR Burnout

Publish Date
Read Time
Ryan Carlson
November 16, 2021

In our video health data series, "Leaders in Leveraging Health Data", we chat with Quality Care Metrics, CEO JJ Richa and Founder/CMO/CVO David Lanzkowsky, MD, FASA.

To avoid EHR burnout and to improve patient care, use diagnostic tools.

Creating a trusting relationship between a doctor and patient is important for a correct diagnosis. Discover how Deep Empathy™ can transform the conversation with patients in the pain management space.


Quality Care Metrics: Improve Patient Care and Avoid EHR Burnout

Ryan Carlson: I'm Ryan Carlson with Healthjump. I'm here with two amazing gentlemen. They're doing some cool stuff with health data. We've got JJ Richa and we've got David Lanzkowsky. Thank you. And you guys are from Quality Care Metrics. And tell me, what is it that you're doing? What's the name of your software?

David Lanzkowsky: The name of the software is Deep Empathy. And what Deep Empathy does it enables physicians, patients to communicate better. And when patients communicate better, it develops a sense of trust. And when patients trust you, they're more likely to tell you openly communicate with you and then get you a better diagnosis.

So my background is in anesthesia and pain management. I've been treating patients with chronic pain for over 25 years. I've been using these emoji scales and numeric rating scales, visual analog scale, zero to 10. And based on that, I have to you know, write prescriptions, do procedures and things like that.

And there's really no objective measure for pain. It's all very subjective. So in 2016, the CDC basically put out these guidelines for weaning patients off opioids. And we started to do that. And that was just like an exercise in futility. One of the patients one day says to me, you don't really know what you're doing, do you?

And I'm like, of course I do. I'm board certified. I've been doing this for 25 years. I know exactly what I'm doing. He said, no you don't. So I throw him out of my practice, I was all mad at the guy. How dare you insult me like that? But I drove home and went to sleep. I woke up the next day and I said, this guy might be right.

I don't really understand pain that well. So I set about finding what was available to better understand pain. And there really wasn't a lot out there. So I started using my own experience to treating these patients. And I knew that they suffered from a magnitude of comorbidities and those included stuff like pain behavior, pain interference, sleep, anxiety, depression, relationships with people, efficacy for managing emotions.

So we put together 16 data points into an interface. So patient would come in, we'd give them, uh, a tablet, a laptop. They fill out the information. And then we'd have this graphic interface that the physician could just look at what was going on. And they could start making determinations as to who they were talking to.

It's almost like a peek into the patients. 

Ryan Carlson: So I've got a question to peek into your, so at what point does JJ come into the story and you guys go, I've been, some guy told me I was wrong and then I thought about it, maybe he was right. And then I've got an idea. 

David Lanzkowsky: So we started to develop the software and actually my son's in Silicon Valley.

And he says, dad, you might have a startup. And I'm like, I didn't even think about that. So JJ is with an incubator group at UCI and we were put in touch with him and JJ. And we've been together since that since, the inception. 

Ryan Carlson: What did that first meeting look like? 

JJ Richa: First meeting was interesting because we didn't know what we're looking at first, but as soon as you start understanding better what Dr. Lanzkowsky has done. You could tell that it was unique. It's one of those things where no, one's done it before, because they're none of the domains that we're looking at. The 16 domains, ask questions directly about how are you suicidal? What's your pain level, one to 10. It's questions around the subject.

And so they can't trick it. It's an adaptive responsive. So if you answer a question a certain way, the next question is maybe different for you than me answering that question. 

Ryan Carlson: So what is the market and who is the customer? Like who is your customer that you are taking this idea and concept to? 

JJ Richa: So, okay. So there, the customer is really, uh, clinics and mainly we're concentrating initially on pain management clinics.

Now we can go. So the 16 domains we're starting with, they can grow into potentially hundreds of domains that we can go into other areas. But initially we're starting with this and really we have three, uh, value propositions for these clinics. The first value proposition, is that what Dr. Lanzkowsky just talked about, is that better communication, the trust between the patient and the provider. 

Ryan Carlson: The question about that. Yes. Right? Cause then we've got two more pillars, so I'm not going to lose it. I'm not going to lose that. 

JJ Richa: We're not losing it. 

Ryan Carlson: The better communication is that just changing the dialogue from, are you on a happy face emoji or is it just like having a better language for talking about how you're feeling?

David Lanzkowsky: So it opens up a whole, like the conversations have completely changed and, uh, my attitude has completely changed towards how we treat patients. You know, in the past, before we had this, um, guys during pain, really patients would come in and they'd have basically three decision points. Am I going to do a procedure?

I'm going to, am I going to write a prescription? Are you potentially drug seeking? Am I gonna toss you out of my clinic, um, or I'm going to order an MRI and the diagnosis we were making prior to using the software were all anatomic diagnoses like degenerative disc disease, lumbar spondylosis, after we started using this.

And this is like with almost near a hundred percent change from everybody using it. The diagnosis then became chronic pain, opioid use disorders, sleep disorders, depression, and anxiety. 

Ryan Carlson: It's like when the DSM started adding and adding more and more spectrums rather than one clinical diagnoses. Right. That's a better way to talk about how you feel how you're reacting that your decision, cognitive decisions.

David Lanzkowsky: Exactly. And then something really interesting happened, was my practice manager came to me and she said, look, you're spending. You know, we get getting; falling behind in the clinic. We're spending a lot more time with patients 

Ryan Carlson: Too many, a lot more questions, right?.

Yeah. Longer questions, more time, you know, just much greater connectivity like this, this conference is about connecting data, right?

So we're really connecting physicians and patients. So interestingly, what happened was, we stumbled into a CPT code that we submitted, that it's actually covered. So we didn't, so then we started getting reimbursed for what we were doing. 

For that diagnostic, intake. Yeah. Effectively. Yeah. Right.

David Lanzkowsky: There's mental health code assessment. 

Ryan Carlson: Yeah. That's fantastic. So that's pillar number one is the communication. I love hearing your examples. What's pillar number two. 

JJ Richa: So pillar number two, two is mitigating risk. So these clinics. Um mostly they're some, sometimes prescribing opioids. And they don't know that, you know, because the patient is saying I'm at a 10.

And you don't understand I'm going to prescribe, but you're not at a 10, who's going to tell me or not. Yep. So, and, and then, so they're putting themselves at risk of maybe potentially losing their license or? Yeah. So that's the pillar number two, pillar number three is what, um, uh, Dr. Lanzkowsky just mentioned, which is the reimbursement.

So it is now, um, increasing the revenue, their net revenue. So it's an additional revenue. Visit, uh, that, that, that the clinic can collect and that revenue ranges anywhere between $60 and $200. And it could be more, depending on many other factors. But, so if you think about it from the standpoint of a clinic that usually gets $30 to $40 per visit.

Yep. Now they're getting an additional $60 or maybe a $100 for that visit. It's really huge. 

Ryan Carlson: And so it's not just, I mean, what I'm hearing and please, please hear me out 

JJ Richa: Three really big things. 

Ryan Carlson: Right. But that third one, though, if, if heard wrong, it could sound like, yeah, there's an extra claim code you can use and make more money, but it's not.

It's getting paid for actual value that intervenes and reduces risk. 

David Lanzkowsky: Let me add two things to what JJ said, as it relates to risk. You know, you have risk of getting sued as a physician, but also if you give the wrong dose of opioid, either too much or too little, you've now risked the patient's outcome. So if you give a patient too little opioids, they're going to oftentimes just find medications in the street that could be cut with fentanyl.

Overdose and things like that right. And if you don't identify an actual drug seeker, you've lost an opportunity to get that patient help. So you decrease the risk for patients. Now, the beautiful thing is about the reimbursement is it then allows you to spend more time because we've actually changed our scheduling.

So we used to see four or five patients in an hour. Maybe. Now we can comfortably see three, spend more time with them and not lose money. You know, if we, if we like with those low reimbursement rates, if you spend. You know, if you're doing a 9, 9 2 1 3 visit and there, you know, depending on who your payor is, that could be, you know, $35 to $60 for that, you know, for that code.

And the MGMA now is saying, it cost about $60 to get a patient in your door. 

JJ Richa: So you're losing money. 

David Lanzkowsky: So you're literally losing money. So if you don't hit a certain number of, of, of patients and this sorry, but this allows you to see less patients, make equal amounts of money, deliver better care. And, and, you know, I mean, staying in business is important, right?

Ryan Carlson: It's the, you know, secure your own mask before securing the mask of others. Right. You can't help others if you're not there to be of assistance. And so the business case makes perfect sense to me. Uh, I'm married to a provider who is an independent provider of services. So the whole claims code and not getting paid for the valuable work that you're doing.

Yeah, totally makes sense. So Ryan and my empathy level, very high. I would love to hear if you know, we're talking about data, you're using data to go into this diagnostic model. Tell me what the unique aspects of your diagnostic model and your software is doing. So business case makes perfect sense why we're doing it, makes perfect sense. Let's talk about the solution a little bit. 

David Lanzkowsky: Sure, sure. And just to add in and just step back one second, it makes perfect sense for the insurance companies. About a third of diagnoses that we do are incorrect. So it's a delayed diagnosis. So the insurance companies, for example, and I'll show you in some of my examples, how we save insurance companies money.

If somebody comes in and they're complaining of back pain, but at some other kind of psychosomatic problem, like loneliness, for example, the right solution might be getting the patient, a service dog, not getting in an MRI and a spine surgery. 

Ryan Carlson: This is also kind of like that principle of measure thrice cut once.

David Lanzkowsky: Exactly. 

JJ Richa: That's where the savings, right? 

Ryan Carlson: Absolutely. Okay. 

David Lanzkowsky: And no, the savings are enormous because if you can, if you can look at the software and see that somebody, you know, all his domains are lighting up red and you do a procedure on that patient, your outcome is going to be guaranteed to fail. 

Ryan Carlson: And, and, you know, the models that you've created, that, you know, you were telling me earlier that the efficacy is very high.

Like, could you share a little bit about like, what the aha moment or the validation looks like.

David Lanzkowsky: We have a patient comes in and sees me. She tells me her pain scores nine out of 10, and I run her through the software. All her domains are green and by green, I mean they're normal within normal limits. So, you know, having done this 30 years, I knew it was virtually impossible to have no comorbidities associated with pain, score nine, whatever that means.

So I said to her what's going on here? And she says, "Well you know, I just came from my attorney's office. I had a slip and fall and he told me if I told you pain doctor, my pain is a score score is a nine, then I'm going to get a better reimbursement." And then she says, "Actually, I don't have any pain." So that was a diagnosis of malingering, which I've made very few times.

It's pretty hard diagnosis to make, but the software just immediately led me to that diagnosis because I had information communication that I'd never previously had. Another patient came, comes in. He tells me his pain scores, zero out of 10. I put him through the software pain interference is lighting up pain behaviors, lighting up.

He can't sleep and I'm like, what's going on here? This is how can you have a pain score? Zero out of 10. And he says to me, well, I've lied to you, doc. I actually, my pain scores. I don't know. Maybe it's a seven, but I need to get back to work. I got kids to feed. And if I tell you that it's a seven, you're going to put me on work restriction and I'm going to lose my job.

So, you know, so that's pretty fascinating. We've had patients come in and, you know, we put them through the, through, through the software and we can see that maybe they're on opioids because they've had failed spine surgery. And we can see if the dose is correct, because you can see that if they're, if their sleep is good.

And if they're depression, anxiety, relationship with people are all good, but their, their, you know, their pain interference and pain behavior lights is slightly orange, you know, yellowish red, you know that they're, they're not gonna use their opioid for. You know, the common, commonly reasons that people misuse opioids is depression and anxiety and sleep.

Ryan Carlson: Absolutely.

David Lanzkowsky: So you know that he's on the right dose and you don't really need to make changes. You can continue there. 

Ryan Carlson: Those things aren't the problem. 

David Lanzkowsky: Right. Right. 

Ryan Carlson: That's really fascinating. Rather than sometimes I feel like it's like a titration guests. It's like it isn't, you know, you're at 40 milligrams, let's try 50.

Right. But not knowing that there are far more, uh, unintended consequences of going in either direction. It sounds like your mom. Isn't just on the pain scale, but it's the other things that happen, right? Like our bodies react to medications, have all kinds of very different ways. And, and this seems like it's a way to diagnose what's happening.

Even if pain is being managed, you might cause other the consequences. 

David Lanzkowsky: Yeah. And that's exactly the word guests is exactly right. Cause that was, that was the frustration. Yeah. That was the frustration I was having. I was going to work and basically guessing and I'd come home going prescribing opioids.

Yeah, no, because there's no better tool do it. Right. 

Ryan Carlson: Walk me through the, the, you know, just the brief elevator picture, uh, of what the patient experience looks like. 

David Lanzkowsky: So the beautiful thing about this is the patient comes in. They can take a link, they can, they get, they get a pain Dyer, basically what we call brief pain inventory, which is a traditional brief pain inventory where you click on where.

What your traditional pain score is with or without medication, right. 

The xes on the elbow, and the, yeah., 

yeah, exactly. Yeah. We've all done that over and over. We give them a series of questions. Questions goes up to the cloud at score to comes down. It's put into a nice interface and the great experiences that I can see, like in the past I used to be sitting here typing, looking over my shoulder.

So where does it hurt? You know? And I'm just distracted using the EHR and talking to the patient. 

JJ Richa: So you're mainly all you're doing is trying to take notes, right? Like data entry of the transaction versus actually talking. 

Ryan Carlson: Now there's a high value skill in the middle of it. Right. Like all I'm doing is capturing data.

JJ Richa: Right. So he doesn't forget. Yeah. I know the biggest thing that, that, uh, physicians are complaining about nowadays is what's called EHR burnout. Yep. Yeah. Cause that's all they're doing. And this opens up that.

Ryan Carlson: So, so, uh, they're in the waiting room, they receive a link. Are they? So they're taking this thing

JJ Richa: Could be home, they. 

They, we can send it to them at home.

Ryan Carlson: So they can do it in advance before the telehealth visit.

So this is enabling the data capture for, you know, all of the tele-health. Right. Fantastic. 

David Lanzkowsky: And then what I like is if, when they come into the clinic, we give them an iPad. It's on a stand, they fill it out in the waiting room. And then the data is then transferred to my EHR. So instead of sitting there with my back towards the patient, I literally, now we've put our, our screens on a, you know, like a wall mount, you know, so now I have this patient come sit next to me.

I'll put the wall mount in front of him and I'll, I'll just be like, Hey, let's go through this and I can talk to them. And oftentimes I don't even have to open my EHR. I don't even need to go into it. 

JJ Richa: So you're looking to the results, right?

David Lanzkowsky: And I don't have my back towards the patients, which is, and the patients, some of them are going, oh, can I print this?

I want to put it, stick it on my refrigerator and follow it. So we've had great patient response. They feel listened to, they feel heard, they feel, you know, empathy, you know, and. 

Ryan Carlson: It's not at the adversarial. I'm telling you what I think you need to hear to give me the outcome that you don't know that I want. 

David Lanzkowsky: Right.

And let me, let me give you just a great, great example is I walked into to a patient the other day, I opened up you know, my deep empathy software. I looked at it and I saw anger flashing. That was the biggest thing on her. So I say, oh, I see you really angry. What's going on? And then she started saying, well, you know, your staff did this and your staff did this and why can't you schedule on time?

And she's just complaining. And I said to her, look, don't blame my staff. Don't blame schedule it's my fault. I had a call. I was inconsiderate of your time and I apologize. And she's like, oh, that's great. That's all I wanted to hear. And then visit just went swimmingly well after that, but it was the ability to just walk in there and just look at a screen and understand the emotion that was predominant.

Yep. And addressing that immediately. And then just communicating, like I've never done before. And what, the other thing this has done is I was literally ready to quit. I had such burnout that I hated going to work. I just felt like, you know, I'm, I'm doing data entry. And then with this, I, I really enjoy going to work and seeing patients again.

And that's been transformative for me. Yeah. You know, having done it this long, I'm like, I don't walk in there thinking, what does this guy want? Is it just one drugs or, you know? 

Ryan Carlson: Yeah. Well, so HIMSS they're talking about, you know, connections and they're talking about data, 

JJ Richa: We're talking about humans. 

Ryan Carlson: I'm talking about humans, which is also the ultimate goal.

JJ Richa: Yeah. Actually there was a conference, a speaker that talked about empathy during the conference. There was one. 

Ryan Carlson: Well, Dr. Lanzkowsky. This idea that not only are you walking this journey, literally side-by-side because you're sitting down and going through this that you're changing the conversation of how am I feeling?

How is other factors in my life, mental, physical, behavioral, all impacting this I, this, this terrible, uh, one-dimensional concept of a pain scale, right? And, and, and turning it into a conversation and not just a guess, diagnosis, and then guess again, right? I mean, that type of, of process is just an ongoing science experiment that you may have that has no real good control.

Right, right. You don't know if they're going to do it on time, you know, you know, there's all this great remote patient care monitoring and remote accountability that, uh, you know, programs are having for like diabetics and for physical therapy. But for pain, no, it seems that all we hear about is the extremes, people that take too much of the medication aren't taking it at all.

And there's no real good way to know. Well, what really is the problem? You're not sleeping enough. You should be exercising more. You're angry, you know, and then it's at me. I'm sorry. Right. Yeah. 

JJ Richa: Um, so I want to mention a couple of things, uh, that, that we didn't mention. So we actually track a history of the treatment.

So Dr. or the provider. Puts a treatment plan in place. So we track that they come back again, we give them the assessment again, and then we keep track of it from beginning to end. So you could see an entire history after six months, nine months, you could see if they're improving or not improving. And so w with, with these graphs and on all the different 16 domains that we have, we have one on the software.

Each one has a different color and you can tell. Are they improving or are they really digressing? And that's, that's really huge. One more thing I want to mention it is NIH approved what we're doing. So it's not just like out of the blue that this is, we just came up with this. 

Ryan Carlson: So, well, I mean the, the results and the, the, the actual human stories to me makes perfect sense.

Right? You it's, it's one thing to go like, yeah, we did this thing. It helps with connection and improvement. But it's clear that this is actually a meaningful change in patient's lives. Uh, and it's by just changing the concert, the literal conversation as is a drinking game. I should, every time I say literal, uh, uh, w we're we're just all people here.

I'm so excited about what you guys are doing. So tell me what's next for quality care metrics and for, uh, you know, your software. Is this something that people are going to be. Buying licenses. Do, do they get trained in how to use the, the, the, the rubric? I mean, what does that look like? 

David Lanzkowsky: I'm gonna let JJ take that one.

JJ Richa: So we have a full, we have a full manual that manual user manual that basically trains the medical assistant. It trains the provider on how to read, how to assess because after, after the, um, the patient takes the assessment and then a provider is presented with all these graphs colorful and they need to interpret them.

And so unless they interpret them properly, they're probably going to misdiagnose. They're probably going to not have the right treatment plan. So what happens is Dr. Lanzkowski and we have videos around it where we actually train them. So they're great. And the provider needs to really do it for, they can't do it for a day or two and say, okay, I'm done there.

Probably need to do it for a couple, three months to really get a quick, uh, a better way of understanding it. So they're able to quickly look at the graphs and say, Hmm, I know what's happening. 

David Lanzkowsky: There's, there's a learning curve to it for the position. 

JJ Richa: A little bit of learning curve. 

David Lanzkowsky: And, but what happens after you do learn it?

It's like computer vision and pattern recognition. You can just see what's going on. It doesn't take that long, but in the initial. You need to spend lots of, lots of additional time, but once you get to that pattern recognition stage, you can process the information pretty quickly, which is great. Um, and the patients have been for the most part, very accepting and really interesting story is that when we, when we started with, um, implementation, you know, there's a lot of complaints from the staff and the patients and it's something new.

Um, and so we started tracking complaints and we did, you know, I would go into the office and I'd hear complaints. Everybody's complaining, nobody wants to do it. So we started tracking. If there's any truth to this and that we did a thousand patients track, we found 70 complaints, which is 7%, three and a half percent were internet related problems.

Like they'd lost a signal or something. Yep. We're down to three and a half percent complaint rate when we divided those, those, that three and a half percent. What we found was half of those complaints were. Just really questions. Like why do you keep asking the same questions over and over? 

Ryan Carlson: How do you answer that question?

David Lanzkowsky: You know, just simple stuff like that. But the other people, you know, they had kind of like more vague complaints and we start drilling down on those big kind of complaint patients. And what we found was they were all on high dose opioids and none of had had, well, I actually followed through on a treatment plan.

So it started to identify potential drug seekers just by the minute you just complain, we can start to see what's going on now. 

Ryan Carlson: Now you know, the rest of the story. 

David Lanzkowsky: That's right. 

Ryan Carlson: That's the thing. I wish more, we had more opportunities just in general when it comes to people like, oh, but they didn't like it.

Oh, well we better change it. Well, why? Right. You'd go to the Toyota method. So the five why's and Kaizen and all that works for a reason. And I'm so glad to hear. And I actually, I'm not surprised in healthcare that we'd have an actual doctor asking diagnostic questions about why we're feeling this way. So, uh, how could people learn more about what you guys are doing?

JJ Richa: So they can go to our website,, or deep, uh, and they could, they could learn more what we're doing also, we're marrying the assessment with intake forms right now. So most clinics they're still on a clipboard. So, so, uh, we we're, we're able to digitize those intake forms and together with the assessments.

So they're, they're one, one piece, right? And so that allows the clinics to be able to, uh, receive information from their new, new, or existing patients and do the assessment at the same time and be able. And then what we're doing is we're adding some intelligence to it. So we could, uh, find out exactly which CPT code fits for a very specific for each patient and what they're doing.

So that way it's, it is kind of an end-to-end solution for the clinic with minimal interference from the staff.

Ryan Carlson: So what people can do expect in their own diagnostic session to hear what their pains are in their practice process and how it is that you'll meet them, where they're at in their journey to, improve. 

David Lanzkowsky: And the data, the data that we can gather is really important in terms of trying to like predict what medications are gonna work. And then you can start creating new drugs with, with micro

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